Free 47837.FH11 - Indiana

APPLICATION FOR APPROVAL OF COSMETOLOGY EDUCATOR FOR CONTINUING EDUCATION
State Form 47837 (R2 / 2-04)

INDIANA PROFESSIONAL LICENSING AGENCY 302 W. WASHINGTON STREET, ROOM E034 INDIANAPOLIS, IN 46204 TELEPHONE: (317) 232-2980

NO FEE INSTRUCTIONS: 1) Attach descriptive course content outline for each course, including a cover sheet for each course indicating course subject, number of hours, and applicable work tools. 2) Attach a completed continuing education instructor application for each instructor. (Retain a blank copy for future use.) 3) Use the enclosed completion certificate to provide to the participants of your course(s). You may reproduce the certificate using your own format, however it must contain all information that is indicated on the board certificate. 4) Check one: Offering: Distance Learning Classroom Both

Name of cosmetology educator (not instructor) Name of director or contact person Educator address (number and street, city, state, ZIP code) Telephone number

PARTNERSHIP / CORPORATION / LLC / LLP INFORMATION
If the ownership of the cosmetology educator is a partnership, LLC / LLP or corporation, please check applicable box and provide ownership information below:

Partnership LLC / LLP Corporation Names and addresses of partners / managers / directors, officers.

COURSES COURSE NAME(S) HOURS COURSE NAME(S) HOURS

Continued on the reverse side

INSTRUCTORS INSTRUCTOR NAME(S) INSTRUCTOR NAME(S)

Do you agree to provide a certificate of course completion to every participant that completes your course(s), using the sample certificate format that is provided with this application? Yes No Have you read and understand the statutes and rules regarding continuing education that were provided with this application? Yes No NOTARY CERTIFICATE I (we) the undersigned, submit this application in conformance with 820 IAC 6 pertaining to cosmetology educator approval. I (we) understand that any violation of the license law or rules on my (our) part will subject me (us) to loss of approval. I (we) certify that the information given in this application is true and correct to the best of my (our) knowledge. STATE OF ________________________________________________
Signature of principal officer, partner, manager or sole proprietor Printed or typed name of principal officer, partner, manager or sole proprietor Date subscribed and sworn to Notary Public County of residence

COUNTY OF: ________________________________________________
Signature of Notary Public Printed or typed name of Notary Public Date commission expires

FOR OFFICE USE ONLY Approved Tabled Reason:

Denied

Reason:

Board signature:

Board signature:

CERTIFICATE OF COMPLETION
THIS IS TO CERTIFY THAT
PARTICIPANT NAME

PARTICIPANT ADDRESS

LICENSE NUMBER

HAS COMPLETED THE FOLLOWING COURSE(S) AT
COURSE(S) (LOCATION) DATE HOURS

EDUCATOR/PROVIDER NAME

INSTRUCTOR NAME

EDUCATOR/PROVIDER ADDRESS

INSTRUCTOR ADDRESS

EDUCATOR/PROVIDER SIGNATURE

INSTRUCTOR SIGNATURE